ADMISSIONS/DISCHARGE/TRANSFER

ADMISSION(ENTERING A HEALTH CARE AGENCY FOR NURSING CARE AND MEDICAL/SURGICAL

TREATMENT)INVOLVES:A. AUTHORIZATION FROM A PHYSICIANB. COLLECTION OF BILLING INFO FROM THE ADMITTING DEPARTMENTC. COMPLETION OF THE ADMISSION PROCESS BY NURSINGD. DOCUMENTING PT’S MED HX & PHYSICAL EXAME. INITIAL MED ORDERS FOR TREATMENT

RESPONSIBILITIES OF THE ADMITTING DEPARTMENT

GATHER INFO FOR BILLING

INITIATE MEDICAL RECORD

PREPARE ID BRACELET. THIS IS THE SINGLE MOST EFFECTIVE WAY OF IDENTIFYING THE PATIENT

MAY BYPASS IN EMERGENCY SITUATION

AN ADDRESSOGRAPH CARD IS MADE

CONSENT FORMS ARE SIGNED, EG. LIVING WILL, DIRECTIVES, WAIVERS

INITIAL ORDERS OBTAINED

VERBAL REPORT GIVEN TO FLOOR RN

PATIENT IS ESCORTED

NURSING RESPONSIBILITES

PREPARE ROOM

IDENTIFY SELF

ORIENT PATIENT

GATHER INFO

PREPARE ROOM

PROVIDE PERSONAL CARE ITEMS

SUCTION

OXYGEN

IV POLE

BED IN HIGH POSITION IF ARRIVING BY GUERNEY

BED IN LOW POSITION IF ARRIVING BY W/C

BLUE PADS IF NEC.

IDENTIFY SELF

MAKES PT FEEL SECURE

MAKES PT FEEL WELCOME

ALLEVIATES ANXIETY/FEAR

ORIENT PATIENTLOCATION OF NURSE’S STATIONCLOTHES STORAGECALL LIGHTBED CONTROLSLIGHT SWITCHESTELEPHONE POLICYTV CONTROLSMEALTIMES

SAFETY MEASURES SUCH AS BEDRAILSVISITING HOURSWHAT TESTS ARE SCHEDULEDDIETROOM BOUNDARIESSCHEDULED SURGERY TIMETIMES FOR DR VISITS

GATHER INFORMATION

THE NURSE WILL GATHER INFO ABOUT:MEDICAL ORDERSTX’SLABSTESTSDIETACTIVITYPHYSICAL ASSESSMENT WITHIN 24HRS.

TYPES OF ADMISSION

INPATIENT

OUTPATIENT

INPATIENT STAY

LONGER THAN 24HRS

PLANNED:NO IMMEDIATE THREATPLANNED ELECTIVE SURGERY, TESTSPT IS PREPAREDEMERGENCY:UNPLANNEDSTABILIZE IN EMERGENCY ROOM (CHEST PAIN, TRAUMA)DIRECT ADMISSION:UNPLANNEDBYPASS EMERGENCY (VOMITING, DIARRHEA)

OUTPATIENT STAY

LESS THAN 24 HRS

OBSERVATIONAL:HEAD INJURYPREMATURE LABORUNSTABLE VITAL SIGNS

VALUABLES

WHEN DOCUMENTING VALUABLES, MAKE SURE TO USE WORDS LIKE:

WHITE/YELLOW METAL NOT GOLDCLEAR STONE NOT DIAMONDS, RUBIES, ETC.HAVE A WITNESSHAVE NURSE & PT SIGN VALUABLES LISTDON’T FORGET DENTURES, GLASSES, ETC.WHEN TRANSFERRING PT, SIGN-OFF WITH NURSEKNOW YOUR FACILITY’S VALUABLES POLICY

PATIENT COMFORTPROVIDE PRIVACY. (SHUT DOOR & PULL CURTAIN.)ASSIST IF NEEDED TO REMOVE CLOTHING AND PUT GOWN ON.PROVIDE EXTRA BLANKETS IF REQUESTED.COLLECT INFO FOR DATABASE.PERFORM INITIAL ADMISSION ASSESSMENT IF APPROPRIATE. (SOME FACILITIES REQUIRE AN RN TO DO INITIAL ASSESSMENTS).OBTAIN PHYSICIAN ORDERS FOR TX’S, LABS, TESTS, MEDS, ACTIVITY, ETC. WITHIN 24HRS.

COMPONENTS OF A MEDICAL HISTORY

•IDENTIFYING DATA

•CHIEF COMPLAINT

•PERSONAL HX

•PAST HEALTH HX

•HX OF PRESENT ILLNESS

•FAMILY HX

•REVIEW OF BODY SYSTEMS

•CONCLUSION

WHAT TO WATCH FOR IN NEWLY ADMITTED PATIENTS

ANXIETY

LONELINESS

DECREASED PRIVACY

LOSS OF IDENTITY

ANXIETY

APPEARANCEExhibits Separation Anxiety.Sad.Worried.Restless.Reduced Appetite.Insomnia.

HOW TO HELPAcknowledge feelings.Provide explanations and instructions before performing procedures.Inquire about stress due to children/pets/spouse at home.Reassure. Separation Anxiety can cause the elderly to be confused and disoriented.

LONELINESS

Make frequent contact with your patient.

Orient your client.

Allow liberal visitation.

DECREASED PRIVACYPull curtain and close door.Knock.Identify room boundaries, esp. if sharing room.Be careful of exposing patient.Patient feels uncomfortable because of unkempt appearance, so announce visitors.

LOSS OF IDENTITY

Call patient by name they prefer.Allow patient to wear own gown.Display pictures.Give them some choices. (bathing, eating, etc.)

DISCHARGETERMINATION OF CARE FROM A HEALTH CARE

AGENCYMETHOD (ACRONYM)M-MEDSE-ENVIRONMENTT-TREATMENTH-HEALTH TEACHINGO-OUTPATIENT REFERRALD-DIETAMA (Against Medical Advice)PT LEAVES PRIOR TO OBTAINING A WRITTEN ORDER. NURSE REQUESTS PT TO SIGN FORM. IF REFUSES, NURSE MUST LET PT LEAVE AND NOTE REFUSAL TO SIGN AMA IN CHART.

NURSES RESPONSIBILITY FOR DISCHARGING A PATIENT

GATHER BELONGINGS/CHECK INVENTORYARRANGE TRANSPORTATIONINFORM PT OF CHECKOUT TIME TO AVOID BEING BILLED FOR AN EXTRA DAYESCORT UNTIL PT SAFELY INSIDE VEHICLEWRITE DISCHARGE SUMMARYTERMINAL CLEANING. BED STRIPPED AND DISINFECTANT USED. BEDSIDE CABINET RESTOCKED/CLEANED.

TRANSFERDISCHARGING A PATIENT FROM ONE UNIT OR AGENCY AND ADMITTING THEM TO ANOTHER UNITINFORMS PATIENT/FAMILYCOMPLETE TRANSFER SUMMARYSPEAKS WITH NURSE ON TRANSFER UNITTRANSPORTS PATIENT/BELONGINGS/SUPPLIES & CHARTCHECKS ORDERS/MAKES NEW ADDRESSOGRAPH CARD W/NEW ROOM #

WHO/WHAT IS INVOLVED IN A PLANNED DISCHARGE?

PHYSICIAN’S ORDER UNIT SECRETARYCALLS FOR TRANSPORT, COPIES CHART/ORDERS

CARE PROVIDER RN OR SOCIAL WORKER

SAFEKEEPING EXTENDED CARE FACILITY

PATIENT NURSE-EXPLAINS DISCHARGE INSTRUCTIONS TO FAMILY/CARE GIVER

SETTING STANDARDS

*REMEMBER*THE AMERICAN NURSE’S ASSOCIATION SETS THE STANDARD FOR PT CARE & DOCUMENTATION FOR RN’SLPN’S ARE GOVERNED BY JCAHDO NOT USE “SEEMS” OR “APPEARS” IN DOCUMENTATION. IMPLIES DOUBT AND LACK OF KNOWLEDGE.STUDENTS DO NOT NEED TO READ P.126-129(EXTENDED CARE FACILITIES) BUT NEED TO READ NURSING GUIDELINES ON TRANSFERRING A CLIENT, P. 126, GENERAL GERONTOLOGIC CONSIDERATIONS & CRITICAL THINKING EXERCISES.